Raw X12 — CIN WQ27235K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0707*|*00501*518430607*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0707*430607*X*005010X279A1~ST*270*0607*005010X279A1~BHT*0022*13*202608120707000001*20260812*0707~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202608120707000001*00000000ND~NM1*IL*1******MI*WQ27235K~EQ*30~DTP*291*D8*20260812~SE*13*0607~GE*1*430607~IEA*1*518430607~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0307*^*00501*167499730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030706*167499730*X*005010X279A1~ST*271*167499730*005010X279A1~BHT*0022*11*202608120707000001*20260812*030706~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202608120707000001*00000000ND~NM1*IL*1*DRIBINSKIY*IZRAIL****MI*WQ27235K~N3*525 NEPTUNE AVENUE            9A~N4*BROOKLYN*NY*11224~DMG*D8*19490208*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*5ED9MJ3VE24~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*167499730~GE*1*167499730~IEA*1*167499730~